title: HIV-infected women on antiretroviral treatment have increased mortality during pregnant and postpartum periods.
abstract: OBJECTIVE
  To assess the impact of pregnancy on mortality among HIV-infected Ugandan women initiating ART.
  
  
  METHODS
  Prospective cohort study.
  
  
  METHODS
  HIV-infected women initiating ART in the Uganda AIDS Rural Treatment Outcomes study were assessed quarterly for self-reported pregnancy. The association between pregnancy and postpartum ('pregnancy-related') follow-up periods and mortality was assessed with Cox proportional hazards models adjusted for age, CD4 cell count, plasma HIV-1 RNA levels, and ART duration.
  
  
  RESULTS
  Three hundred and fifty-four women with median age 33 years (IQR: 27-37) and CD4 142 cells/μl (IQR: 82-213) were followed for a median of 4.0 years (IQR: 2.5-4.8) after ART initiation, with 3 and 7% loss-to-follow-up at years 1 and 5. One hundred and nine women experienced pregnancy. Five deaths occurred during pregnancy-related follow-up and 16 during nonpregnancy-related follow-up, for crude mortality rates during the first year after ART initiation of 12.57/100 PYs and 3.53/100 PYs (rate ratio 3.56, 95% CI: 0.97-11.07). In adjusted models, the impact of pregnancy-related follow-up on mortality was highest at ART initiation (aHR: 21.48, 95% CI: 3.73-123.51), decreasing to 13.44 (95% CI 3.28-55.11) after 4 months, 8.28 (95% CI 2.38-28.88) after 8 months, 5.18 (95% CI: 1.36-19.71) after 1 year, and 1.25 (95% CI: 0.10-15.58) after 2 years on ART. Four of five maternal deaths occurred postpartum.
  
  
  CONCLUSIONS
  Pregnancy and the postpartum period were associated with increased mortality in HIV-infected women initiating ART, particularly during early ART. Contraception proximate to ART initiation, earlier ART initiation, and careful monitoring during the postpartum period may reduce maternal mortality in this setting.
authors.affiliation: aDivision of Infectious Disease, Massachusetts General Hospital, Center for Global Health bDivision of Infectious Disease, Beth Israel Deaconess Medical Center, Boston, Massachusetts cSimon Fraser University, Faculty of Health Sciences, Burnaby, Canada dDepartment of Epidemiology and Biostatistics, University of California at San Francisco, San Francisco, California eUniversity of British Columbia, School of Population and Public Health, Vancouver, Canada fMbarara University of Science and Technology, Mbarara, Uganda gDepartment of Medicine, Massachusetts General Hospital, Center for Global Health, Boston, Massachusetts hUniversity of California at San Francisco, Department of Medicine, San Francisco, California, USA.
authors.forename: Lynn T
authors.initials: LT
authors.lastname: Matthews
authors.forename: Angela
authors.initials: A
authors.lastname: Kaida
authors.forename: Steven
authors.initials: S
authors.lastname: Kanters
authors.forename: Helen
authors.initials: H
authors.lastname: Byakwagamd
authors.forename: A Rain
authors.initials: AR
authors.lastname: Mocello
authors.forename: Conrad
authors.initials: C
authors.lastname: Muzoora
authors.forename: Annet
authors.initials: A
authors.lastname: Kembabazi
authors.forename: Jessica E
authors.initials: JE
authors.lastname: Haberer
authors.forename: Jeffrey N
authors.initials: JN
authors.lastname: Martin
authors.forename: David R
authors.initials: DR
authors.lastname: Bangsberg
authors.forename: Peter W
authors.initials: PW
authors.lastname: Hunt
mesh_terms: D000328:Adult; D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D018791:CD4 Lymphocyte Count; D015331:Cohort Studies; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000401:mortality*; D015497:HIV-1 / Q000302:isolation & purification; D006801:Humans; D049590:Postpartum Period; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000188:drug therapy* / Q000401:mortality*; D011446:Prospective Studies; D012367:RNA, Viral / Q000097:blood; D016019:Survival Analysis; D014454:Uganda; D019562:Viral Load
chemical_list: D044966:Anti-Retroviral Agents; D012367:RNA, Viral